Should biofeedback therapists blush? Some thoughts on the subject of self regulation in the treatment of Blushing.

Arnon Rolnick, PhD

This post deals with a question which is on one hand focused on specific symptom, but on the other hand is very much central to our concepts about control and the ability to let go.

While I was working in the navy in the 1980s, I was  approached by a young girl who worked with the sailors and she asked me if I could help her reduce her tendency to blush. She was a shy young girl who blushed whenever social attention was directed towards her. At that time (1985) the reports about biofeedback and relaxation treatment for hot flushes (freeman 1996, 2003) were not yet published .

On the face of it (pun intended) blushing or redness of the face are easy to treat with biofeedback as we have a clear correlate of physiological blushing:  a cheek plethysmograph,  cheek temperature, or the use of laser doppler flowmetry. The simplest biofeedback conceptualization suggests to train people to reduce blood flow to the cheeks. How can it be then, that there is no biofeedback treatment for blushing? The Yucha and Gilbert booklet (2008) does not include blushing or fear of blushing in its efficacy studies. One might wonder whether blushing is not that important? Darwin would not agree; he wrote that blushing is the most peculiar and the most human of all expressions.

In a recent review of the proposed criteria for Social Anxiety Disorder (SAD) in the DSM 5 it is suggested that ” Blushing is a hallmark physical sign of SAD and seems to be unique to

SAD”. How then, have we have not studied it? Maybe we should blush?

I believe we should indeed blush. As many of you know, the leading textbook in our field”Biofeedback: A Practioner Guide” authored by Schwartz and Andrasik, does not include a chapter on anxiety disorders (although I hope that the next edition will include such a chapter written by my group).

Might one explanation as to why there is a lack of information about biofeedback as a treatment for blushing and social anxiety disorder be that our concept is wrong? Could it be that in order to treat blushing it is better to accept  or ignore it rather than attempting to control it?  The 3rd wave generation of Cognitive Therapy suggests that CBTis too  focused on change,in opposition to acceptance. ACT is only one example of a therapeutic approach that teaches patients to observe reality without judgment or criticism, and to cease efforts that are made in the struggle against anxiety. Biofeedback can certainly assist in this particular aspect of change. Hamiel and Rolnick(in press)  recently argued that biofeedback can enhance cognitive behavior therapy in exactly this  arena.

Returning to the question of whether we should we blush? I think the case of blushing suggests that biofeedback can enhance the therapy of anxiety disorders in general, and social anxiety in particular, by being a unique tool for simulating blushing or simulating a situation where the patient feel shame for the fact that other people can see their stress. There is a strong parallel between blushing, which usually occurs only when the subject is in a social or interpersonal situationand the triadic situation where the patient is aware that the therapist sees their internal reaction, and this is a unique type of exposure that other CBT methods can not create as easily, or at all..

I would appreciate any comment about helping socially anxious subjects with biofeedback, and. also your views on whether biofeedback therapists should blush..

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